JOGNN RESEARCH

Maladaptive Coping With Illness in

Women With Polycystic
Ovary Syndrome
Sven Benson, Susanne Hahn, Susanne Tan, Onno E. Janssen, Manfred Schedlowski, and Sigrid Elsenbruch

Correspondence
Sven Benson, PhD, RGN,
University Hospital of Essen
Medical School, Department
of Medical Psychology and
Behavioral Immunobiology,
Hufelandstr. 55, 45122
Essen, Germany.
sven.benson@uk-essen.de
ABSTRACT
Objective: To investigate associations between active and passive coping, psychiatric symptoms of depression and
anxiety, and quality of life in women with polycystic ovary syndrome (PCOS). To assess the relative contribution of
these coping strategies to reduced quality of life in an attempt to clarify the possible relevance of coping for impaired
psychosocial well-being in PCOS.
Design: Internet-based survey.
Participants: 448 German women with PCOS.

Keywords Methods: Coping (Freiburg Questionnaire of Coping-with-Illness), anxiety and depression (Hospital Anxiety and
polycystic ovary syndrome Depression Scale [HADS]), and quality of life (Short Form 12 Health Survey [SF-12]) were assessed in an Internet-
coping based survey. Correlation and regression analyses were conducted.
anxiety
depression Results: In women with PCOS, passive coping was significantly associated with greater anxiety (r 5 .65; p o .001),
quality of life depression (r 5 .61; p o .001), and reduced psychological quality of life (r 5 .64, p o .001). In stepwise multiple
regression analyses, passive coping, together with depression, anxiety and body mass index (BMI), explained 50.1%
of the SF-12 psychological sum score, while active coping did not enter any regression model.
Conclusion: Data suggested that faced with the diagnosis of PCOS, passive coping may constitute a maladaptive
strategy associated with anxiety and depression symptoms and compromised quality of life. Hence, efforts to in-
corporate psychosocial aspects into counselling and care for women with PCOS should take coping strategies into
consideration. Nurses and other health care providers may help to improve coping strategies through education and
psychosocial support in women with PCOS.
JOGNN, 39, 37-45; 2010. DOI: 10.1111/j.1552-6909.2009.01086.x
Accepted October 2009

Sven Benson, PhD, RGN,
is an assistant professor in
the Institute of Medical
Psychology & Behavioral
Immunobiology, University
Hospital Essen, Essen,
Germany.
Susanne Hahn, MD, is an
endocrinologist in
endocrine practice in
Wuppertal, Germany.
Susanne Tan, MD, is a
resident in the Department
of Endocrinology and
Division of Laboratory
Research, University
Hospital of Essen, Essen,
Germany.
(Continued)
olycystic ovary syndrome (PCOS) is a common
P endocrine disorder affecting about 6% of
women of reproductive age, characterized by
gynecologic and endocrine symptoms, including
chronic anovulation, infertility, and hyperandro-
genism. Many women with PCOS also suffer from
obesity and insulin resistance, both harbingers of
metabolic syndrome and type 2 diabetes mellitus
(Guzick, 2004). In recent years, a growing number
of studies reported markedly increased psycholog-
ical distress including feelings of depression,
anxiety, and social fears in women with PCOS
(Himelein & Thatcher, 2006; Janssen, Hahn, Tan,
Benson, & Elsenbruch, 2008; Jones, Hall, Balen, &
Ladger, 2008). Women with PCOS may fail to con-
form with societal norms for outer appearance and
may thus feel stigmatized (Kitzinger & Willmott,
2002). Symptoms of PCOS reportedly have a detri-
mental impact on various aspects of quality of life,
including physical, social, and emotional dimen-
sions (Himelein & Thatcher; Janssen et al.;
McCook, Reame, & Thatcher, 2004).
Furthermore, women with PCOS have an increased
lifetime incidence of psychiatric diagnoses includ-
ing depression, anxiety disorders, and suicide
attempts (Mansson et al., 2008), which re£ects the
extent and clinical relevance of the psychological
dysfunction associated with PCOS. These psycho-
logical implications need to be recognized by
nurses so they may seek to improve quality of life of
their patients through education and psychosocial
support (McCook et al., 2004; Snyder, 2006). However,
the psychological mechanisms that mediate the risk for

http://jognn.awhonn.org & 2010 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses 37
RESEARCH
The psychological implications of polycystic ovary
syndrome need to be recognized by nurses and other
health care providers to improve quality of life through
education and psychosocial support.
Onno E. Janssen, MD, is an
endocrinologist in the
Endokrinologikum
Hamburg Center for
Endocrine and Metabolic
Diseases, Hamburg,
Germany.
Manfred Schedlowski,
PhD, is a professor and
director of the Institute of
Medical Psychology &
Behavioral Immunobiology,
University Hospital of
Essen, Essen, Germany.
Sigrid Elsenbruch, PhD, is
an assistant professor in the
Institute of Medical
Psychology & Behavioral
Immunobiology, University
Hospital Essen, Germany.
38
psychological disturbances in PCOS are incomple-
tely understood and should therefore be the aim of
interventions.
Coping mechanisms constitute an important medi-
ator of the relationship between a stressful situation
and the resulting psychological distress (Lazarus &
Folkman, 1984). In the medical context, coping pro-
cesses are induced whenever an acute or chronic
condition confronts a patient with threats and chal-
lenges that compromise his or her emotional
balance (De Ridder & Schreurs, 2001). Evidence
from various patient populations supports that cop-
ing with illness is associated with emotional well-
being and quality of life (Lechner, Bolman, & van
Dalen, 2007) and even possibly with health out-
comes (Faller & Buelzebruck, 2002). Two basic
coping strategies are often postulated (Folkman &
Lazarus, 1988). Active problem-orientated coping
is characterized by active efforts to solve a problem,
such as seeking information about the diagnosis
and treatment, joining a support group, or seeking
out medical specialists (Folkman & Greer). On the
other hand, emotional or passive coping comprises
strategies to reduce the aversive emotions evoked
by the stressful situation, for instance brooding,
self-pitying, arguing with fate, or withdrawing from
other people (Folkman & Greer, 2000). Previous ev-
idence suggests that passive coping is associated
with increased stress and symptom severity (Le-
chner et al.). Active coping may be protective for
psychosocial well-being (Folkman & Lazarus), es-
pecially in situations that are highly controllable by
the individual (e.g., nutrition). However, in situations
beyond the control of the individual (e.g., preterm
labor), active coping may be harmful (De Ridder &
Schreurs; Folkman & Greer).
Coping has thus far not been analyzed in women
with PCOS, although the typical symptom constella-
tion of PCOS clearly implies numerous threats and
challenges, such as changes in outer appearance,
involuntary childlessness, and long-term health
risks. Coping with PCOS may modulate psychoso-
cial well-being. Therefore, the goal of this study
was to assess coping strategies and their associa-
tion with psychosocial well-being in women with
PCOS that may affect psychological well-being
(Folkman & Greer, 2000). We aimed to investigate
JOGNN, 39, 37-45; 2010. DOI: 10.1111/j.1552-6909.2009.01086.x
Coping With Polycystic Ovary Syndrome
the relationships between active and passive
coping, psychiatric symptoms of depression and
anxiety, and quality of life in a sample of German
women with PCOS. Based on ¢ndings in other
patient populations (Badura, Reiter, Altmaier,
Rhomberg, & Elas, 1997; Lechner et al., 2007), we
hypothesized that in women with PCOS, active,
problem-oriented coping would be protective, and
passive coping would be associated with enhanced
psychiatric symptoms and decreased quality of life.
Our second, explorative aim was to use multiple re-
gression models to assess the relative contribution
of these coping strategies to reduced quality of life
in women with PCOS in an attempt to clarify the
possible relevance of coping for psychosocial well-
being in this population.
Methods
Participants and Procedure
Data were collected using an online questionnaire
as previously described in detail by Benson et al.
(2009). The link was posted on the homepage of
the German PCOS patient support group (http://
www.pcos-selbsthilfe.org). In Germany, multiple
support groups in all larger cities and/or regions
are organized together in a network that was initi-
ated and coordinated by members of the PCOS
working group (O.E. Janssen, S. Hahn, S. Tan). As
part of this initiative, the German PCOS website
was created, and its contents are continuously up-
dated by members of the group. The survey was
announced on this website, and background infor-
mation on the goals of the study was available on
the website. To prevent access for nonpatients, the
link that opened the questionnaire was only accessi-
ble to registered users of the German PCOS support
group. Each participant received an individual pass-
word that allowed access to the questionnaire and
provided the opportunity to reenter and complete
the questionnaire at a later time point, if necessary.
The password was created automatically by the
provider of the Internet test platform (Hogrefe Test
Systems, G˛ttingen, Germany, http://www.hog
refe-testsystem.com). Participants were informed
that data were collected anonymously and
stored on a separate server (Hogrefe Test Systems,
G˛ttingen, Germany).
Respondents were only included if they stated that
the diagnosis of PCOS had been established by an
endocrinologist or a gynecologist. Further, only re-
spondents aged 16 to 45 years were included who
reported medically con¢rmed symptoms according
to the Rotterdam criteria (Rotterdam ESHRE/ASRM-
Sponsored PCOS Consensus Workshop Group,
http://jognn.awhonn.org
Benson, S., Hahn, S., Tan, S., Janssen, O. E., Schedlowski, M., and Elsenbruch S.
2004), for example, two of the following criteria:
oligomenorrhea (cycles lasting longer than 35
days) or amenorrhea (less then two menstrual cy-
cles in the past 6 months), hyperandrogenism
(hirsutism, obvious acne, or alopecia), and polycys-
tic ovaries. By basing our con¢rmation of the
diagnosis on self-report and physical (rather than
biochemical) signs of hyperandrogenism, the pro-
portion of PCOS women with only elevated
testosterone and polycystic ovaries or oligo-/ame-
norrhea may be underrepresented in this sample.
The survey took place from December 2006 until
August 2007 and was approved by the Ethics Com-
mittee of the University of Duisburg-Essen.
Internet Questionnaire
The questionnaire was programmed and provided
using an Internet-based test platform (Hogrefe
Testsystem, G˛ttingen, Germany). It covered socio-
demographic, clinical, and psychological areas.
Participants were instructed to complete the re-
quested information or to check the appropriate
answers. Sociodemographic information, including
age, family status, education, and employment
were assessed. To con¢rm the PCOS diagnosis, the
presence of medically con¢rmed symptoms
was evaluated according to the Rotterdam criteria
(Rotterdam ESHRE/ASRM-Sponsored PCOS Con-
sensus Workshop Group, 2004) (answering
options are shown in brackets): cycle disturbances
(cycleso35 days; cycles  35 days; less than two
menstrual cycles in the past 6 months ; not sure),
presence of hirsutism, obvious acne, alopecia
(each yes/no), polycystic ovaries (yes/no/not sure).
Body weight and body size were also recorded, and
body mass index (BMI) was calculated as [body
weight in kg/(body size in m) 2].
Psychological Measures
Psychological measures included the online ver-
sions of three validated questionnaires. Coping
was assessed using of the short version of the
Freiburg Questionnaire of Coping with Illness
(Freiburger Fragebogen zur Krankheitsverarbei-
tung, FKV) (Muthny, 1988), which is partly based on
the Ways of Coping Checklist (Lazarus & Folkman,
1984) and is commonly used to assess coping strat-
egies in Germany. The FKV contains 35 short
statements regarding coping behavior that are
completed using a 5-point Likert-type scale (0 5
not at all, 4 5 very much). Based on these items,
scale scores representing ¢ve coping styles (active
problem-orientated coping, passive/depressive
coping, distraction, spirituality, and minimizing im-
portance) were calculated with higher scores
indicating a more pronounced use of this coping
JOGNN 2010; Vol. 39, Issue 1
RESEARCH
style in an individual. The active, problem-oriented
coping scale consists of ¢ve items, namely seeking
information about illness and treatment, intending
to live more intensively, making plans of action
and following through with them, deciding to ¢ght
against the illness, undertaking problem-solving
efforts. The passive/depressive coping scale com-
prises items assessing brooding, arguing with
fate, withdrawing from other people, acting impa-
tiently and taking it out on others, and pitying
oneself. Based on our sample, Cronbach’s a 5
0.78 (a 5 0.77 for the normative population as pub-
lished by Muthny) for passive/depressive coping,
a 5 0.73 (a 5 0.73 for normative population) for
active coping, for distraction a 5 0.60 (a 5 0.71
for normative population), a 5 0.52 (a 5 0.68
for normative population) for spirituality, and a 5
0.68 (a 5 0.73 for normative population) for mini-
mizing importance.
Given that our primary interest was in the broader
concepts of active and passive coping, and the
remaining three scales (distraction, spirituality, min-
imizing importance) had comparatively poor
psychometric quality, we performed descriptive
statistics for all scales but included only active and
passive coping into the correlation and regression
analyses. This strategy has previously been
adopted also by other groups (Faller & Bu-
elzebruck, 2002; Nickel, Wunsch, Egle, Lohse, &
Otto, 2002).
Normative patient data for the FKV scales are avail-
able for a mixed patient sample consisting of
patients with myocardial infarction, multiple sclero-
sis, and renal failure. Because the FKV assesses
coping in the context of medical conditions, the
questionnaire is not suitable for use in healthy per-
sons. Hence, no normative data for healthy controls
are available. It should clearly be pointed out that
the comparison of PCOS with the available norma-
tive patient dataset is hampered by obvious
differences in diagnoses. However, to the best of
our knowledge, no validated German questionnaire
with a more appropriate patient control group exists.
In addition, our primary analyses were designed to
address implications of coping within PCOS.
Anxiety and Depression
Anxiety and depression were assessed using the
German version of the Hospital Anxiety and De-
pression Scale (HADS) (Herrmann-Lingen, Buss, &
Snaith, 2005) as previously described in detail by
Benson et al. (2009). The HADS consists of 14 items
that address various aspects of depression and
anxiety in the past 7 days. The scale can be divided
39
RESEARCH
into two subscales (anxiety and depression), with
higher sum scores indicating more anxiety and de-
pression, respectively. Sum scores o8 indicate the
normal range, scores 8 to 10 re£ect mild alterations,
and scores  11 indicate clinical relevance of
symptoms (Herrmann-Lingen et al.). Cronbach’s
a 5 0.80 for the HADS anxiety subscale and a 5
0.81 for the HADS depression subscale (for the nor-
mative population published by Herrmann-Lingen
et al.). The sensitivity (83.3%) and speci¢city
(61.5%) for the identi¢cation of psychiatric cases
were acceptable (Herrmann-Lingen et al.).
Health-Related Quality of Life
The German version of the SF-12 (Short Form 12
Health Survey), the short version of the widely used
SF-36, was used to assess health-related quality of
life (Bullinger & Kirchberger, 1988). The SF-12 ad-
dresses the impact of physical health complaints
on different dimensions of quality of life, namely
physical function, physical role function, bodily
pain, general health, vitality, social function, emo-
tional role function, and mental health (Bullinger &
Kirchberger; Ware, Kosinski, & Keller,1996). Scoring
results in two global health measures, the Physical
and Psychological Sum score, with higher scores
indicating improved quality of life. The SF-12 con-
tains 12 out of the 36 Likert-type scaled items that
explain 490% of the variance of the original SF-
36 (Ware et al.). The German version of the SF-12
has satisfying psychometric properties; Cronbach’s
a 5 0.87 for the Physical Sum Score and a 5 0.80
for the Psychological Sum Score (Bullinger &
Kirchberger).
It is important to note that we did not use a disease-
speci¢c PCOS questionnaire given that validated
instruments (Jones et al., 2008) are not available in
German. Although well-established generic instru-
ments such as the SF-12 do not assess all speci¢c
aspects of PCOS, they do allow comparisons with
other patient and normative samples and provide a
valid and sound assessment of the most relevant
broad areas of quality of life.
Statistical Analyses
We scored and analyzed all questionnaires (FKV,
HADS, SF-12) according to the respective manuals
(Bullinger & Kirchberger, 1988; Herrmann-Lingen
et al., 2005; Muthny, 1988). Correlations between
the FKV scales active problem-orientated and pas-
sive coping, respectively, and the HADS depression
and anxiety scales with SF-12 physical and psycho-
logical quality of life sum scores were computed as
Pearson’s r. To assess the contribution of coping on
quality of life, we conducted two stepwise multiple
40 JOGNN, 39, 37-45; 2010. DOI: 10.1111/j.1552-6909.2009.01086.x
Coping With Polycystic Ovary Syndrome
regression analyses for physical and psychological
quality of life (SF-12 sum scores), respectively. As
predictors, we included FKV subscales active and
passive coping and the HADS subscales depres-
sion and anxiety. To control for clinical and
sociodemographic variables, age, BMI, education,
and partnership status were additionally included
as predictor variables.
Additionally, group means on all validated scales
were compared to the respective German reference
populations (German norm) using one-sample t
tests. The HADS and SF-12 scores were compared
to the appropriate German female norm (Hinz &
Schwarz, 2001) as previously described (Benson et
al., 2009). The FKV scores were compared to the
German patient reference population (Muthny,
1988), which consists of patients with acute and
chronic diseases such as myocardial infarction,
multiple sclerosis, and need of dialysis. As noted
earlier, any significant group differences must be in-
terpreted with caution given obvious differences
between PCOS and these mixed diagnoses.
Results
Sociodemographic & Clinical Character-
istics
A total of 466 women completed the online ques-
tionnaire. Out of those, 16 women were excluded
who did not meet Rotterdam criteria, and two were
excluded who were older than 45 years of age.
Hence, data from 448 women with PCOS were in-
cluded. Mean age was 29.6  5.5 years. Further
information regarding sociodemographic and clini-
cal characteristics including partnership status,
number of children, BMI, and PCOS symptoms are
provided in Table 1.
Psychological Characteristics of
the Sample—Comparison With
Normative Data
Women with PCOS were characterized by signi¢-
cantly enhanced depressive symptoms and anxiety
(both p o .001 vs. German female norm for HADS).
Psychological quality of life was significantly im-
paired in women with PCOS (p o .001 vs. German
female norm), whereas physical quality of life was
comparable to the German female norm (p 4 .05
vs. German female norm) (Table 1). Women with
PCOS reported significantly more passive coping
with illness compared to the German patient nor-
mative population (derived from Muthny, 1988) (p
o .001). On the other hand, no significant di¡er-
ences were observed for active problem-orientated
coping with illness (p 5 .67). Small but in light of the
http://jognn.awhonn.org
Benson, S., Hahn, S., Tan, S., Janssen, O. E., Schedlowski, M., and Elsenbruch S. RESEARCH

Table 1: Sociodemographic, Clinical and Psychological Characteristics Patients With

PCOS (N 5 448)
PCOS Normative Data p
Age, mean (SD) 29.6 (5.5) ç ç

BMI, mean (SD) 30.0 (8.2) ç ç

2
Obesity (BMI  30 kg/m ), % (n) 54.0 (242) ç ç

Family status

Married, % (n) 46.7 (209) ç ç

With partner, % (n) 32.4 (145) ç ç

With children, % (n) 24.3 (97) ç ç

Unful¢lled wish to conceive, % (n) 55.6 (249) ç ç

Hirsutism, % (n) 65.6 (294) ç ç

Acne, % (N) 43.5 (195) ç ç

FKV passive coping, mean (SD) 2.9 (0.9) 1.9 (1.1) a o .001
a
FKV active problem-orientated coping, mean (SD) 3.4 (0.7) 3.4 (1.3) ns

FKV distraction, mean (SD) 3.0 (0.6) 2.9 (1.2) a

o .001

FKV spirituality, mean (SD) 2.5 (0.7) 2.7 (1.1) a

o .001

FKV minimizing importance, mean (SD) 2.7 (1.0) 2.2 (1.3) a

o .001

HADS depression, mean (SD) 7.2 (4.0) 3.2 (3.1) b o .001

HADS anxiety, mean (SD) 9.0 (4.2) 4.6 (3.2) b o .001

c
SF-12 physical quality of life, mean (SD) 48.3 (8.7) 47.9 (9.7) ns

SF-12 psychological quality of life, mean (SD) 38.3 (10.8) 51.3 (8.4) c
o .001

Note. PCOS 5 polycystic ovary syndrome; BMI 5 body mass index; FKV 5 Freiburg Questionnaire of Coping with Illness; HADS 5 Hos-
pital Anxiety and Depression Scale; SF-12 5 Short Form 12 Health Survey; SD 5 standard deviation; ns 5 not significant.
For psychological variables, comparisons with respective reference populations (German norm) were computed.
a
Normative data from Muthny (1988).
b
normative data from Hinz and Schwarz (2001).
c
Normative data from Bullinger and Kirchberger (1988).

large sample size statistically significant differences
were observed for the FKV subscales distraction (p
o .001), spirituality (p o .001), and minimizing im-
portance (p o .001) (Table 1).
Correlations Between Coping, Psychiatric
Symptoms, and Quality of Life
Passive coping with illness was associated with great-
er anxiety (r 5 .65, p o .001) and depression (r 5 .61,
p o .001) as well as with reduced quality of life (for
psychological sum score: r 5 .64, p o .001; for
physical sum score: r 5 .21, p o .001). On the
other hand, active coping was not correlated with ei-
ther anxiety (r 5 .02, p 4 .05) or psychological
quality of life (r 5 .03, p 4 .05). The correlations
with depression and physical quality of life, respec-
tively, were relatively small (for depression: r 5
.19, p o .001; for physical sum score: r 5 .10,
p o .05).
Coping as Predictor of Quality of Life
To address the relative contribution of coping to re-
duced quality of life within PCOS, stepwise multiple
regression analyses were carried out for SF-12
physical and psychological sum scores. HADS anx-
iety and depression scores, FKV subscales active
and passive/depressive coping, age, BMI, educa-
tion, and partnership status were included as
predictor variables (Table 2). For SF-12 physical
sum score, BMI, HADS depression, HADS anxiety,
and age entered the regression model (F 5 81.7,
p o .001). Predictors of SF-12 psychological sum
score (F 5 109.1, p o .001) were FKV passive/de-
pressive coping, HADS depression, HADS anxiety,

JOGNN 2010; Vol. 39, Issue 1 41

RESEARCH Coping With Polycystic Ovary Syndrome

tive strategy that is associated with anxiety and

Passive coping may constitute a maladaptive strategy that
is associated with anxiety and depression symptoms
and compromised quality of life in women with
polycystic ovary syndrome.
depression symptoms and compromised quality of
life. Hence, efforts to incorporate psychosocial as-
pects into counseling and care for women with
PCOS should take coping strategies into consider-
ation.

and BMI.The regression models explained 25.6% of
the variance of SF-12 physical sum score (corrected
R 2 5 0.256) and 50.1 % of SF-12 psychological sum
score (corrected R 2 5 0.501), respectively.
Discussion
It is widely recognized that women with PCOS have
significantly reduced quality of life (Himelein &
Thatcher, 2006; Janssen et al., 2008; Jones et al.,
2008), and this was also evident in this sample of
participants who demonstrated markedly reduced
psychological quality of life. The present analysis
constitutes the ¢rst to assess the association be-
tween quality of life, psychiatric symptoms of
anxiety and depression, and active and passive
coping with illness in women with PCOS. In sum-
mary, passive coping was strongly correlated with
symptoms of anxiety and depression as well as with
lower quality of life whereas active coping was only
marginally associated with these variables. Further,
passive coping emerged as a significant predictor
of psychological quality of life, independent of
effects of anxiety, depression, and BMI. Together,
these data suggest that faced with the diagnosis of
PCOS, passive coping may constitute a maladap-
Consistent with our hypothesis, we observed signif-
icant correlations between passive coping and
symptoms of anxiety and depression, as well as
quality of life. Furthermore, passive coping was an
independent and significant predictor of impaired
quality of life. Indeed, the amount of variance in psy-
chological quality of life that was predicted by
passive coping alone was remarkable (40.5%), the
total model explaining approximately 50% of the to-
tal variance in psychological quality of life. Findings
from other patient populations suggest a detrimen-
tal effect of passive coping on psychiatric symptoms
and quality of life.
For example, passive coping was reportedly
associated with depression, anxiety, and grief in
couples with an unful¢lled wish to conceive (Le-
chner et al., 2007). In longitudinal studies, passive
coping predicted impaired quality of life in cancer
patients 2 years after radiotherapy (Sehlen et al.,
2003) and predicted increased depression in wo-
men after miscarriage (Bergner, Beyer, Klapp, &
Rauchfuss, 2008). Based on these ¢ndings, one
may speculate that our results indicate that passive
coping is maladaptive in PCOS and may constitute
a risk factor for and/or a contributor to impaired

Table 2: Results of Stepwise Multiple Regression Analyses With SF-12 Physical Sum
Score and SF-12 Psychological Sum Score as Criteria
Quality of Life Predictor Variable B b t p Adj. R 2
Physical sum score (SF-12) BMI 0.37 .35 8.2 o .001 .158

HADS depression 0.39 .19 3.4 o .001 .237

HADS anxiety 0.32 .15 2.7 o .01 .248

age 0.16 .10 2.4 o .05 .256

Constant 69.5 29.0

Psychological sum score (SF-12) FKV passive coping 0.37 .34 7.1 o .001 .405

HADS depression 0.86 .33 6.9 o .001 .485

HADS anxiety 0.84 .14 2.9 o .01 .495

BMI 0.38 .09 2.5 o .05 .501

constant 56.9 28.5

Note. BMI 5 body mass index ; HADS 5 Hospital Anxiety and Depression Scale; SF-12 5 Short Form 12 Health Survey; FKV 5 Freiburg
Questionnaire of Coping with Illness. As predictor variables, FKV active and passive coping, HADS depression, HADS anxiety, BMI, age,
education and partnership status were included.

42 JOGNN, 39, 37-45; 2010. DOI: 10.1111/j.1552-6909.2009.01086.x http://jognn.awhonn.org

Benson, S., Hahn, S., Tan, S., Janssen, O. E., Schedlowski, M., and Elsenbruch S.
psychological quality of life and psychiatric risk in
PCOS.
Surprisingly, the expected (negative) associations
of active coping with anxiety, depression, and qual-
ity of life were absent or very small. These ¢ndings
clearly argue against our hypothesis that active
coping may constitute a protective factor in PCOS.
However, it must also be acknowledged that the as-
sumption of active coping as protective and passive
coping as detrimental is not unequivocal and might
be rather simplistic. For example, in women with
preterm labor, passive coping was found to be pro-
tective while active coping had adverse effects on
gestational age (Demyttenaere, Maes, Nijs, Ode-
ndael, & van Assche, 1995). In fact, there is
convincing empirical evidence indicating that situ-
ations that can be controlled are better dealt with
by employing a problem-focused coping style,
whereas passive, emotion-focused coping strate-
gies are superior in situations beyond control (De
Ridder & Schreurs, 2001). In the case of PCOS, ac-
tive coping may help to get disease-speci¢c
information and to better deal with speci¢c symp-
toms, such as cosmetic problems or obesity, and
therefore to improve psychosocial well-being and
quality of life.
Limitations
The use of an online questionnaire via the home-
page of a PCOS self-support group allowed us to
assess a comparatively large sample of women with
PCOS. Although this precluded objective con¢rma-
tion of the diagnosis, including only registered users
of the PCOS homepage minimized the risk that par-
ticipants misreported their PCOS status. Similarly,
because data on body weight and height were
self-reported, the BMI reported herein should be in-
terpreted with caution. Of note, this Internet-based
approach bears the possibility of a self-selection
bias, because this online tool may have led to an
overrepresentation of participants with relatively
higher educational and/or socioeconomic back-
grounds. In addition, participants of this survey
have actively sought support through a support
group or the associated Internet forum, which may
re£ect an active coping strategy. Hence, the present
participants may not be representative for the entire
PCOS population.
Women with PCOS were compared to normative
populations, and no healthy control group was re-
cruited. Although this may be viewed as a
limitation, it is important to point out that the FKV
assesses coping in the context of medical condi-
JOGNN 2010; Vol. 39, Issue 1
RESEARCH
Evaluation of coping strategies in women with polycystic
ovary syndrome may help to identify those at risk for
impaired psychosocial well-being.
tions, and hence the questionnaire is not suitable
for use in healthy individuals. Furthermore, di¡er-
ences in psychosocial well-being and quality of life
between women with PCOS and healthy controls
have previously been well documented (Else-
nbruch et al., 2003) and are beyond the scope of
this survey. Therefore, we feel that the main goal of
this survey was not hampered by the lack of a
healthy control group.
Obviously, no causal relationships between coping
and psychological risk can be deduced given the
cross-sectional nature of our data set. Furthermore,
psychiatric conditions such as depression are ex-
pected to alter coping strategies, and our data do
not allow to disentangle possible interactions be-
tween psychiatric status and coping style.
Implications for Nursing and
Health-Care
McCook et al. (2004) and Snyder (2006) empha-
sized that psychosocial aspects of PCOS need to
be recognized by the nursing community. This is
supported by ¢ndings that only a minority of treat-
ing physicians provides information on cosmetic
problems and long-term health management (Cus-
sons, Stuckey, Walsh, Burke, & Norman, 2005).
Nurses and other health care providers can help to
improve quality of life of women with PCOS through
education and psychosocial support. The evalua-
tion of maladaptive coping strategies (passive
coping) in women with PCOS may help to identify
those at risk for impaired psychosocial well-being
and psychiatric morbidity. Coping mechanisms
can easily be assessed by nurses by specifically
asking about how women cope with PCOS
symptoms (What do you do to maintain your
body weight? How do you deal with feelings
of frustration?). Additionally, validated coping
questionnaires such as the Ways of Coping Check-
list by Lazarus and Folkman (1984) may be used
(at least for native English speakers). Knowing
how women cope with PCOS can provide im-
portant information for education and psychosocial
support.
Interventions that help women to cope more e¡ec-
tively with PCOS should be implemented and
evaluated. Patient education should include the
43
RESEARCH
provision of disease-speci¢c information and ad-
vice (e.g., ways to handle cosmetic problems such
as body hair and acne). Further, nurses should em-
power their patients to actively engage in and
support the treatment of their PCOS, for example,
through optimal weight management (Markle).
Importantly, patients must understand the impor-
tance of treatment adherence in the light of
long-term health risks associated with PCOS. The
implementation of stress management techniques
may help to reduce psychological distress (Markle,
2001). It has further been established that be-
havioural interventions can successfully modify
coping strategies (Kennedy, Du¡, Evans, & Beedie,
2003) and thereby contribute to improved psycho-
social adjustment to illness and enhanced
psychological well-being in other medical condi-
tions (Chesney, Chambers, Taylor, Johnson, &
Folkman, 2003; Kennedy et al.). With respect to psy-
chosocial support, a positive, respectful and
empathic attitude will help to understand the wo-
men’s worries and needs associated with the
diagnosis of PCOS. Health care providers must rec-
ognize that not only the patient, but also her partner
and family may be affected (Markle). Nurses and
health care providers should also be aware of feel-
ings of depression, anxiety, or social fear and liaise
with a psychotherapist in the case of severe emo-
tional burden. In conclusion, educating women
with PCOS may help to actively handle this condi-
tion, and therefore help to overcome passive
coping.
Acknowledgments
Financed by departmental funds.
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